A nurse is caring for a mother who delivered vaginally 2 hours ago.Select the 4 findings the nurse should report to the provider.
Fundus midline and firm at the umbilicus.
Moderate lochia rubra with no clots.
Constant trickle of blood at the vagina.
Hemoglobin level.
Heart rate.
Correct Answer : C,D,E
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Herbal tea is not scientifically proven to reduce breast engorgement and may not be effective.
Choice B rationale
Warm compresses applied before feeding help to soften the breasts, making it easier for the baby to latch and reducing engorgement.
Choice C rationale
Letting the baby drain one breast completely at each feeding can help prevent engorgement but is not specifically for managing existing engorgement.
Choice D rationale
Feeding every 3-4 hours may not be frequent enough to prevent engorgement, especially in the early days of breastfeeding.
Correct Answer is A
Explanation
Choice A rationale
Antibiotics should be taken for the full prescribed course, typically 10-14 days, to ensure complete resolution of the infection. Stopping antibiotics early can lead to recurrence or resistance.
Choice B rationale
Continuing to breastfeed while having mastitis is encouraged as it helps keep milk flowing and prevents blockage.
Choice C rationale
Taking analgesics for pain relief is appropriate during mastitis as it helps manage discomfort and supports continued breastfeeding.
Choice D rationale
Wearing a supportive bra helps alleviate discomfort and supports the breasts, which is beneficial during mastitis.
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